LJ Sure Mercies

Updated 20 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

One inspector carried out this inspection and an Expert by Experience was used. An Expert by Experience is a person who has personal experience of using or caring for someone who uses the service.

Service and service type

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats and specialist housing.

Registered Manager.

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post.

Notice of inspection

We gave the service 48 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the registered manager would be in the office to support the inspection.

What we did before the inspection

We reviewed information we had received about the service. The provider was not asked to complete the required Provider Information Return. This is information providers are required to send us with key information about the service, what it does well and improvements they plan to make. We took this into account in making our judgements in this report.

During the inspection

We reviewed a range of records. This included 3 people’s care records and 1 person’s medicine records. We looked at 3 staff files in relation to recruitment and staff supervision. We spoke with the registered manager, director, and office worker. We reviewed records related to the management of the service, which included training records, safeguarding incidents, quality assurance records and a range of policies and procedures. After the inspection we spoke with 4 people and 4 relatives and 2 staff members.

Updated 20 July 2023

About the service

LJ Sure Mercies is a domiciliary care agency. It provides personal care to people living in their own homes. At the time of the inspection there was 9 people using the service. The service provides support to older people, people and people living with dementia.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided.

People’s experience of using this service and what we found

Medicines were not always managed in a safe way. Risk management plans were not always detailed and did not give staff clear guidance to help mitigate risks. The provider needed to introduce more robust systems to monitor the service as they did not identify the issues we found during the inspection. We made a recommendation to the provider to implement more robust monitoring procedures. The registered manager took prompt action to address the issues we found during the inspection.

Staff were recruited safely. People were notified when staff were running late. The registered manager was recording all accidents and incidents, and these were discussed in team meetings to improve practice.

The registered manager was not recording staff’s induction process which meant we could not be assured they had the training to carry out their role. People’s nutritional needs were recorded. People receiving care, relatives and staff told us they felt the service was well run.

Staff completed training and received support to ensure they had the appropriate skills to meet people's care needs in a safe and effective manner. People’s needs were assessed, and this information was used to help the registered manager agree the person’s care needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People’s care was personalised, and it was clear that staff knew people well. The registered manager had procedures in place for dealing with complaints.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 3 September 2021, and this is the first inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

Recommendation

We made a recommendation to the provider to implement more robust procedures for monitoring the service.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.